Activity 3.3.

1: Medical History – Visit #1

Patient’s Name: Age: Date:
Melissa Martin 11 February 5
Height: Weight: Temperature:
52 inches 70 lbs. 98.3°F
Blood Pressure: Pulse: Respiration Rate:
110/72 75 bpm 22 bpm

Case History
Melissa is an 11-year-old girl who has been having coughing fits for the past 6
days. Her mom is concerned as her school reports that she has been
reluctant to participate in gym class. Melissa states that she is embarrassed
that she can’t keep up with her friends. She has also been having trouble
lasting her entire ballet class without feeling tired or starting to cough.
Melissa’s records report five upper respiratory infections and associated
coughing in the past 18 months. Mild wheezing is reported at each of these
appointments. Melissa describes the cough as “dry” and says during these
times of infection, she wakes up coughing more than once a night.

Physical Exam
● Patient’s pulse is normal. Pulse ox = 91%
● No wheezing is appreciated on this appointment.
● Patient said she has no ear pain or a sore throat. Upon inspection, her ears,
nose, and throat all look normal.
● Patient’s glands are not swollen.
● Patient’s speech, hearing, and vision appear normal..

Explanation of Symptoms

Recommendations

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Human Body Systems Activity 3.3.1 Medical History – Visit #1 – Page 1